A majority of patients with coronavirus disease 2019 (COVID-19) and respiratory failure can tolerate prolonged prone positioning, a practice that may improve oxygenation and reduce mortality, according to a research letter published in JAMA.

The study included a total of 24 awake, nonintubated patients who were admitted to a single center in France between March 27 and April 8, 2020, for COVID-19 and hypoxemic acute respiratory failure requiring oxygen supplementation. Investigators from this hospital took arterial blood gas measurements before and during prone positioning as well as 6 to 12 hours after resupination. The primary outcome was the proportion of responders, defined as an increase of ≥20% in partial pressure of arterial oxygen (PaO2) between before and during prone positioning.

Additional study outcomes included PaO2 and partial pressure of arterial carbon dioxide (PaCO2) variation, defined as the difference in PaO2 and PaCO2 between before and during prone positioning or after resupination. Feasibility and the proportion of persistent responders were also assessed. The investigators also monitored adverse events. Patients were followed for up to 10 days.

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The median duration between hospital admission and first prone positioning was 1 day. Approximately 17% (n=4) of the study participants with COVID-19 did not tolerate prone positioning >1 hour, whereas 21% (n=5) tolerated prone positioning for 1 to 3 hours. The majority of patients (63%) tolerated prone positioning for >3 hours. A total of 6 (25%) patients were considered responders to prone positioning (95% CI, 12%-45%), which represented 40% of the 15 patients who sustained prone positioning for ≥3 hours (95% CI, 20%-64%). There were 3 patients who were considered persistent responders to prone positioning.

In the subgroup of patients who sustained prone positioning for ≥3 hours, the PaO2 increased from a mean of 73.6 mm Hg to 94.9 mm Hg from before prone positioning to during prone positioning, respectively (difference, 21.3 mm Hg; 95% CI, 6.3-36.3 mm Hg; P =.006). There was no difference between the period before prone positioning and after resupination in regard to PaO2 (P =.53).

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There were no major complications associated with prone positioning. Approximately 42% (n=10) of patients reported back pain. Invasive mechanical ventilation was reported in 5 patients at the end of the 10-day follow-up. Of these patients, 4 did not sustain prone positioning for ≥1 hour, and these patients required intubation within a 72-hour period.

Study limitations included the small sample size, the single-center design, the assessment of a single prone positioning episode, and the short duration of follow-up.

The investigators suggested that additional “studies to identify optimal [prone positioning] regimens and patients with COVID-19 in whom it may be beneficial are warranted.”

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Elharrar X, Trigui Y, Dols A-M, et al. Use of prone positioning in nonintubated patients with COVID-19 and hypoxemic acute respiratory failure [published online May 15, 2020]. JAMA. doi:10.1001/jama.2020.8255